A comprehensive eHealth implementation guide constructed on a qualitative case study on barriers and facilitators of the digital care platform CMyLife

Background Substantial proliferation of eHealth has enabled a move in patient-centred cancer care from the traditional in-person care model to real-time, dynamic, and technology supported on-demand care. However, in general, the uptake of these innovations is low. Studies show that eHealth is helpful in providing patient empowerment through e.g. providing high quality and timely information, enabling self-monitoring and shared decision making, but dropout rates are high and guidance for optimal implementation is lacking. Aim To explore barriers to and facilitators for nationwide implementation and consolidation of CMyLife, a multi-component, patient-centred, digital care platform, and to construct a comprehensive implementation guide for launching digital care platforms in daily clinical practice. Methods The first qualitative case study of a digital care platform like CMyLife was performed including five focus group- and eighteen in-depth interviews with stakeholders. Data were collected using a semi-structured interview guide, based on the frameworks of Grol and Flottorp. Transcripts of the interviews were analysed and barriers and facilitators were identified and categorized according to the frameworks. An iterative process including participation of main stakeholders and using the CFIR-ERIC framework led to creating a comprehensive implementation guide for digital care platforms. Results In total, 45 barriers and 41 facilitators were identified. Main barriers were lack of connectivity between information technology systems, changing role for both health care providers and patients, insufficient time and resources, doubts about privacy and security of data, and insufficient digital skills of users. Main facilitators mentioned were motivating patients and health care providers by clarifying the added value of use of a digital care platform, clear business case with vision, demonstrating (cost) effectiveness, using an implementation guide, and educating patients and health care providers about how to use CMyLife. Based on these barriers and facilitators a clear and comprehensive implementation guide was developed for digital care platforms. Conclusion Several barriers to and facilitators for implementation were identified, a clear overview was presented, and a unique comprehensive implementation guide was developed for launching future digital care platforms in daily clinical practice. The next step is to validate the implementation guide in other (oncological) diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08020-3.


Format focus group interviews CMyLife
Background CMyLife platform CMyLife has two main goals: -Give patients control of their CML care; this requires optimal patient information -Organize hospital free care Why put 'control in the hands of the patients'?
• The patient can then ensure that his/her blood levels are checked on time (and receives his/her blood result on time).
• Patient knows how to act after receiving his/her blood results.
• Patient receives feedback on his medication intake (insight into the relationship between his/her medication intake and his/her blood value.
• Patient can make his/her complaints known and receive feedback on them.
• Patient is provided with all the information that the care provider wants to provide him/her. How is that organized: with the help of digital tools (website CMyLife, medication app & guideline app, bcr-abl charts and personal health environment), feedback from healthcare providers and the CMyLife support desk for patients and healthcare providers.
Why hospital-free care?
• Patient is free to visit the hospital. How is that organized: process change in each hospital via local blood tests, delivery of medication, video consultation by the hospital's specialized nurse.

Situation at the Radboudumc
In the Radboudumc CMyLife e-clinics has already been partially implemented (website & apps are available, local blood tests, delivery of medication and video consultation (now also by haematologists) are possible). However, implementation of CMyLife e-clinics in other Dutch hospitals will not happen automatically. A first step to realize implementation in other Dutch hospitals is to make an inventory of barriers and facilitators among people who have contributed to the implementation at Radboudumc, the CMyLife project group. This inventory takes place with the use of a focus group interview and is carried out in the context of the ZonMw action research.

Structure and purpose of the focus group interviews
As indicated above, we initially organize a focus group discussion with the CMyLife project group. This will allow us to get a better picture of the experiences with the implementation of CMyLife e-clinics and of possible barriers and facilitators for implementation. The goal is to hear as many experiences as possible without striving for consensus or saturation. In addition to the group discussion with the project group, the project members who cannot attend the focus group discussion will be interviewed separately (a second focus group may be planned). The previous inventory of 'stakeholders' who have a role in national implementation, from the project group meeting on the 11 th of June, is supplemented from the group discussion and the additional discussions. In a second interview round, focus group and/or individual interviews are planned with them.

Performance interviews
Practical issues -Arrange space or room to perform the interviews -Create+sent invitation letter for participants -Create+sent infromation to participants (important to have a factsheet about the apps) -Working (recording) equipment -Arrange and fill out Informed consent forms -Provide short questionnaires on participants background characteristics, pens and paper to create nametags.

Points of attention in advance
• The interviewer must have a good idea of the distribution of the topics in her/his head; • During the conversation it is important to verify whether it is the opinion of a respondent and possibly reflect on the aforementioned opinions; • When a participant does not express his opinion or to a lesser extent, the interviewer tries to stimulate a respondent with previously inventoried opinions.
• Asking questions, trying to understand the participant's perspective; • Do not defend or explain; • Listen to whether the respondent answers the question, be alert; • Do not move on to the next topic too quickly, but take breaks after a participant has said something; •

INTRODUCTION
-Introduction of our research concerning CMyLife e-clinics -Emphasize confidentiality and voluntariness, as well as confidentiality of recording and data processing -Propose to tutor each other during the interview and whether there is any objection to this --Time indication, mention break -Are there any questions before we start?

INDIVIDUAL INTRODUCTION Introductory question
CMyLife is largely implemented at the Radboudumc. The next step is implementation in other hospitals, on the way to national implementation and consolidation. If you look at that, what barriers do you expect? What are factors that can facilitate implementation? We will discuss this on the basis of the 6 domains of the Grol & Wensing framework (innovation itself, individual professional, patient, social setting, organizational context, economic & political context (financing or legislation & regulations). your first reaction to this question? With regard to CMyLife, by this we mean all parts, so both the parts needed for 'patient in control' and the parts needed for 'hospital-free care'.

TOPICS
 Topic: CMyLife / eHealth apps Which barriers do you expect, in relation to the implementation of CMyLife in other hospitals, in the field of CMyLife, the innovation itself?
-What barriers have you experienced at Radboudumc in the field of innovation itself? -What barriers do you expect in other centers? Do you expect differences between the different types of hospitals (UMCs, large peripheral, small peripheral)? What are facilitators for the implementation of CMyLife in other hospitals, in the field of CMyLife, the innovation itself?
- -What is working well in the Radboudumc? -Does this apply to CMyLife as a whole? Or does this apply to certain parts? Examples: -Knowledge regarding the implementation of an e-health innovation -Attitude towards the implementation of an e-health innovation, e.g. do you expect to use it? -Motivation regarding the implementation of an e-health innovation, e.g. What is your prediction that you will use CMyLife in the coming months? What is needed (what needs to change) in the field of the individual professional to facilitate implementation in other hospitals?  Topic: economic and political context Which barriers do you expect, in relation to the implementation of CMyLife in other hospitals, in economic and political context?
-What barriers did you experience in economic and political context at the Radboudumc? -What barriers do you expect in other hospitals in economic and political context? What are facilitators for the implementation of CMyLife in other hospitals, in economic and political context?
-What is working well in the Radboudumc? -Does this apply to CMyLife as a whole? Or does this apply to certain parts? Examples: -Financial arrangements -Laws and regulations -Policy -ownership What is needed (what needs to change) in economic and political context to facilitate implementation in other hospitals?
 Topic: Significance of CMyLife for the way of working as a caregiver Question: what does CMyLife mean for the work and way of working? For example, think of: -How a doctor or nurse takes notes -Additional tasks